Kingdom of Saudi Arabia

‫المملكة العربية السعودية‬

MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

ORTHOPEDIC
NAME EMPLOYEE NUMBER:
:
ID NUMBER: YEARS OF
EXPERIENCE:
SAUDI COUNCIL REGISTRATION #: DATE OF EXPIRATION:

Designation:

 RESIDENT  SPECIALIST  CONSULTANT

Certification/s:
 BCLS  ACLS  ATLS  PALS  Other/s (please specify)________________

Clinical Privilege Category:

 TEMPORARY  APPROVED  EMERGENCY
At the time of a life-threatening clinical emergency, any Practitioner may render whatever care he/she believes to
be indicated regardless of the extent of his/her granted privileges.

Instructions:
APPLICANT: In the first column below, place a check in the appropriate box whether you have requested for the
privileges listed on the second column.
GENERAL INSTRUCTION: Please tick () in the appropriate column whether the privileges that the applicant
applied for is “GRANTED”, “GRANTED WITH SUPERVISION” or “DENIED”. (If the requested privileges
are either “GRANTED WITH SUPERVISION” or “DENIED”, the “REMARKS” column may be necessary to be
filled up).
Note: A copy of this privilege list will be given to the applicant. The original privilege list will be kept in the
“Personnel File”. The Clinical Privilege of Medical Staffs will be reviewed every 2 years along with their Annual
Evaluation for Contract Renewal or as necessary. (For New Medical Staffs, review of privilege will be after 90
days from the start of employment.)

REQUESTED GRANTED
CLINICAL
GRANTED WITH DENIED REMARKS
YES NO PROCEDURES
SUPERVISION
GENERAL (BASIC) PROCEDURES

MS-001 (2) Page 1 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

ORTHOPEDIC
  Admitting Privileges   
Conscious IV
Sedation
    
(May require
Anesthesia approval)
CATEGORY 1
A. GENERAL ORTHO. (TRAUMATIC)
Conservative
treatment of all upper
and lower extremity
fractures by casting,
    
skin or skeletal
tractions, arm slings or
other forms of
immobilization.
B. OPERATIVE TREATMENT OF ALL UPPER AND LOWER EXTREMITY CLOSED FRACTURES
UPPER LIMB
Hand closed fractures
(Carpal, Metacarpal
    
and Phalyngeal
fracture)
Distal radius fractures.

REQUESTED GRANTED
CLINICAL
GRANTED WITH DENIED REMARKS
YES NO PROCEDURES
SUPERVISION
UPPER LIMB-CONTINUATION
Forearm both bones
    
shaft fractures
Proximal radius and
    
ulna fractures.
Humeral shaft
    
fractures.

MS-001 (2) Page 2 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

ORTHOPEDIC
Proximal humeral
    
fractures.
Scapular neck
    
fractures.
  Clavicle fractures   
C. OPEN FRACTURE TREATMENTS
Wound debridement
    
and external splinting.
D. OPEN FRACTURE TREATMENTS
  Closed reduction   
CATEGORY 2
A. GENERAL ORTHO. (NON-TRAUMATIC)
Arhrocenthesis and
  intra articular   
injections.
Ganglion
    
Management.
  Carpal tunnel release.   
  Trigger finger release.   
  Tarsal tunnel release.   
  Septic arthritis.   
  Osteomyelitis.   
BLOOD TRANSFUSION AND INFUSION
Infusion ( IV Fluids,
    
plasma, etc.)
  Intravenous medicines   
Blood transfusion- whole,
    
packed cells

If at any stage you wish to perform any surgical or therapeutic procedure that is not listed in this application, you
must refer to the Credentialing and Privileging Committee.

CLINICAL PRIVILEGES APPROVAL

MS-001 (2) Page 3 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

ORTHOPEDIC
STAMP &
NAME & DESIGNATION DATE
SIGNATURE

Requested by:
___________________________

Recommended by: Dr. Anwer Nehal Ghouri

Head of Orthopedic Department

Dr. Anwer Nehal Ghouri

Medical Director/
Medical Credentialing & Privileging Committee
Chairman
Approved by:

Mr. Ibrahim Hamad Mana Al Amer

Hospital Director

MS-001 (2) Page 4 of 4